Informatics 98may8

Journal of Informatics in Primary Care 1998 (May):22-25


Articles


Meeting the Information Challenge in General Practice

* Malcolm Colledge, Advisor in Primary Health Care Research

Alistair Carson, IT Co-ordinator and Researcher

T Stuart Murray, Professor of General Practice

Department of General Practice, University of Glasgow, Woodside Health Centre, Barr Street, Glasgow G20 7LR. Tel 0141-332 8118 Fax 0141-332 3402

* All correspondence to Malcolm Colledge

 

Introduction

With the reforms in the NHS over the last few years, culminating in the white papers for England and Scotland, general practitioners have been increasingly involved in planning and needs assessment1,2. Recent research findings have stressed the need for reliable information and data gathering3.

During a needs assessment project in the West of Scotland, we worked towards developing a general practice profile which could capture unique local features. At that time we explored the potential use of Geographical Information Systems (GIS) modelling in general practice. The success of this approach demonstrated the need to develop an ‘engine’ to improve the quality of data in general practice, so that it could be mapped with reliability4.

The level of data available in general practice systems is variable and some GP computers are little more than word processors used for such routine activities as repeat prescribing5. Other practices have amassed large amounts of data on morbidity, prescribing and intervention, but unless the data is set in context it is often meaningless. Another problem with general practice data sets is the lack of consistency in setting parameters, that is, consensus between GPs on the interpretation of ‘Read codes’. Most of these data, if marshalled correctly, have important features to inform needs assessment and resource allocation.

Using the experiences gained in sixteen practices in Scotland, and two in Northern Ireland, we developed a relational database ‘engine’ that can deal with data from GPASS, EMIS, VAMP etc, rendering it into a aggregated form suitable for viewing practice characteristics. The resulting package is called the ‘General Practice Data Analysis Toolbox’.

 

Objectives & Methods

Our initial objective was to provide a user-friendly relational database which allows easy access to patient data. Once the system is in place, we intend to monitor its use and develop the package based on ideas from the users themselves.

The database was created by extracting patient information from GPASS, EMIS, VAMP, etc., into the Toolbox (see Figure 1). Using these data, a prototype analysis facility was developed, customised and automated to meet the information needs of practice teams. Development continued using an evolutionary series of systems design stages carried out at a task level within the pilot practices6.

Figure 1: The Toolbox

For ease of use and practical purposes the Toolbox was created using standard hardware and software, compatible with Windows™ 3.11 and Microsoft Office™ Professional. Customisation is within Microsoft Access™, which is used for data input, analysis and graphical presentation. Although the Toolbox comes with a standard set of analyses its design background means that it is easily enhanced and adapted to meet the demands of particular practices or localities in fundholding or commissioning.

The Toolbox was finally developed in an inner-city practice in Glasgow. This practice has approximately 7,500 patients. The profile was created in consultation with the practice and was filtered from GPASS to cover morbidity, intervention and drug class (see Table 1). This exercise allowed for the development of a demonstration package of the Toolbox, with a manual for installation in future practices. Names and addresses of patients have been removed from the demonstration to meet confidentiality criteria.

Table One: Data Profile

Morbidity Intervention Drug Class
Angina

Asthma

Diabetes Mellitus

Dyspepsia

Endometriosis

Heart Failure

Hypertension

Ischaemic Heart Disease

Peptic Ulcer

Reflux Oesphagitis

Angioplasty

Chest X Ray

Echo Cardiography

Lung Function

No Echo Cardiogram

Ace Inhibitors

Asthma Preventors

Asthma Relievers

Beta Blockers

Calcium CBs

Combination Diuretics

Drugs for Diabetes

Loop Diuretics

Losec

Thiazide Diuretics

Nitrate Spray

Nitrates

No Ace Inhibitors

Proton Pump Inhibitors

 

What does the Toolbox do?

  • Allows immediate access to summarised and aggregated patient data for needs assessment. The more specific the request the faster the result.
  • Targets specific groups of patients by age, sex, and location, linking morbidity to intervention and prescription (see Figure 2).
  • Provides immediate access to patient details for target groups for screening and mailshots.
  • Provides spatial information by age, diagnosis and prescription.
  • Acts as a platform for mapping patients by locality (using Geographical Information Systems add-on).
  • Allows for regular import of updated data from GPASS, etc.
  • Provides tables, graphs, histograms and pie charts for practice reports (see Figure 3).
  • Provides data for needs assessment and locality planning.

 

Figure 2:

 

 Figure 3:

The basic Toolbox can be installed and up and running within four days allowing the practice access to basic information. The Toolbox has been used in the design practice to carry out several audits, for example, diabetes and checking current prescribing guidelines for asthma. The Toolbox has subsequently been installed in a further four sites comprising:

  • A multifund made up of three practices in North East Scotland which are investigating cardiovascular disorders.
  • An inner-city practice in Edinburgh addressing mental health problems in a deprived community.
  • Two practices in Northern Ireland, one concentrating on a retrospective picture of the distribution of diagnosed brain tumours, and the other carrying out a diabetic audit.
  • A pilot practice in a seven-practice multifund in NW England.

From February 1998 the Toolbox will be installed in general practices throughout the United Kingdom. The target number of sites will be 200. A monitoring project will be carried out to evaluate the current version and develop a ‘Version Two’ of the Toolbox, with customised integrated GIS application. This will be developed by using Map Info and Data Map from Microsoft Office™ Professional.

 

Conclusions and Future Developments

The immediate attraction of the Toolbox lies in its ability to allow GPs to visualise their patients as a community and to assess their health needs. Successful implementation of the Toolbox depends on involving all the practice team, especially those responsible for maintaining practice database records. In the pilot practices a member of the practice team has been appointed to co-ordinate the project and create a team spirit and a willingness to participate by other members of the team.

By taking a team approach the full potential of the Toolbox can be exploited providing a unified ‘grass roots’ input into purchasing decisions. Setting up the Toolbox also gives an insight into weaknesses in a practice database, for example, inaccurate postcodes, historical recording inaccuracies and prescribing errors.

Use of the Toolbox can help to shape a primary care focus that is person-centred and needs-led, facilitating good quality care and cost effectiveness. It also allows for empowerment of the general practitioner when commissioning in the NHS of the future.

If health needs assessment in general practice in the community is to be meaningful, this "bottom up" view must be related to "top down" national data to provide a rounded view of the local community, either by individual practice or by locality. The co-operation of Health Boards and Authorities and the use of other data sources with the Toolbox can provide a unique opportunity for resource planning.

During the monitoring and evaluation of the Toolbox we will be exploring its use against the timetable of changes flowing from the changes in primary health care as outlined in the white papers, especially the general practitioners role in commissioning and the setting up of Primary Health Care Groups and Trusts (Scotland).

Finally, we are planning to move towards a relational database that can provide ‘trial solutions’ based on a ‘soft systems methodology’ optimised to balance possible conflicting health care requirements against the available local and national resources7. Thus the Toolbox will provide a "What If?" model for strategic decision-making on a practice or locality basis.

 

Acknowledgments

The project is supported by an educational grant from Zeneca. We would like to thank all the practices involved. Also Eugene Gallagher, Western Health and Social Services Board, Northern Ireland for his support, and Anita Colledge for editing and proofreading the paper.

References

1 Designed to Care: Renewing the National Health Service in Scotland. Cm 3811. The Scottish Office. December 1997.

2 The New NHS, Modern, Dependable. Cm3807. HMSO. December 1997.

3 Gillam SJ, Murray SA. Needs Assessment in General Practice. Occasional Paper 73, Royal College of General Practitioners, London, October 1996

4 Colledge M, Maxwell H, Parker R, Morse DJ. Geographical Information Systems in General Practice: A New Tool for Needs Assessment. Journal of Informatics in Primary Care; 1996 (Mar):7–11

5 Newbery G. Maximising Information in A Primary Care-Led NHS. Ed. Meads G. Churchill Livingstone, 1996

6 Crinnion J. Evolutionary Systems Development. Pitman, 1991

7 Checkland P, Scholes J. Soft Systems Methodology in Action. Wiley, 1996

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